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Published on: November 8, 2024
Uncomplicated linear skull fractures in the paediatric population: a retrospective observational study in a UK Major
Vesta S Najmi1, Sivasri Krishna Yellamraju1, Emma Toman1,2
1Department of Neurosurgery, Birmingham Children's Hospital, Birmingham, UK.
Insights
Children with linear skull fractures rarely deteriorate and do not need inpatient neuro-observation. This study supports current guidelines and suggests safe discharge protocols for these pediatric patients.
Area of Science:
- Pediatric Neurosurgery
- Trauma Care
- Clinical Guidelines
Background:
- National Institute of Clinical Excellence (NICE) guidelines suggest no admission for pediatric linear skull fractures without intracranial injury.
- UK practice often involves inpatient neuro-observation due to concerns about deterioration.
- This practice contrasts with international findings and current evidence.
Purpose of the Study:
- To determine the incidence of neurological deterioration in pediatric patients with linear skull fractures.
- To evaluate the necessity of inpatient neuro-observation for these patients.
- To inform UK trauma network protocols regarding linear skull fractures.
Main Methods:
- Retrospective review of pediatric patients with linear skull fractures referred to a major trauma center (2018-2023).
- Exclusion of patients with intracranial injury, skull base fracture, or major trauma.
- Primary outcome: neurological deterioration (defined by GCS drop, repeat imaging, neurosurgical intervention, or death).
Main Results:
- 294 pediatric patients identified with linear skull fractures.
- Infants (44.2%) were the most common age group; falls from <2m height were the most common mechanism (71.4%).
- No patients experienced neurological deterioration, aligning with international studies.
Conclusions:
- This study, the largest UK cohort, found no neurological deterioration in pediatric linear skull fractures.
- Findings support NICE guidelines and question the routine need for inpatient neuro-observation.
- Recommends developing protocols for safe emergency department discharge to reduce healthcare costs.
Purpose:
National Institute of Clinical Excellence (NICE) guidelines advise that paediatric patients with linear skull fractures do not require admission in the absence of intracranial injury. Despite this, a period of inpatient neuro-observation has become the standard advice and practice in the UK for fear of deterioration. Our experience is that these children rarely deteriorate or require neurosurgical intervention. The primary aim of this study was to describe the incidence of neurological deterioration in patients referred to our paediatric neurosurgery unit with linear skull fractures.
Methods:
We identified all patients with a linear skull fracture referred to neurosurgery at a paediatric major trauma centre between 2018 and 2023. Patients with intracranial injury, skull base fracture or major trauma were excluded. Demographic and clinical data were collected. The primary outcome was deterioration which was defined as drop in Glasgow Coma Scale (GCS) score, unplanned repeat cranial imaging, neurosurgical intervention performed, or the patient died.
Results:
Two hundred and ninety-four patients were identified in our referral database. Infants were the age group most commonly referred (44.2%) and falls from under 2 m in height the most common mechanism of injury (71.4%). Ninety-seven children had specific advice documented regarding neuro-observation; of these, the majority (n = 53) were advised 24 hours of inpatient observation. No patients experienced deterioration.
Conclusions:
This is the largest cohort of linear skull fractures in children described in the UK. None of our patients experienced neurological deterioration, mirroring findings from international studies and supporting current NICE guidance. In addition, at a cost of £360 per 24-hour admission, this has a cost implication for a resource-scarce NHS. We propose that UK trauma networks should devise protocols to support the safe discharge from ED of such patients without the need for discussion with a neurosurgical department.
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